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PRACTICE: Adnan Bhutta, Craig Gilliam, Michele Honeycutt, Stephen Schexnayder, Jerril Green, Michele Moss, and K J S Anand Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach BMJ 2007; 334: 362-365 [Abstract] [Full text]

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Practice not perfect

Rhys T Lewis   (18 February 2007)

Practice not perfect 18 February 2007
Rhys T Lewis, SHO in Anaesthetics & ITU St Richard's Hospital, Chichester. PO19 6SE Send response to journal: Re: Practice not perfect	While it is, as always, commendable that the authors of this paper took clearly effective steps to remedy what was a significant local problem, the results don't/shouldn't show us anything new in terms of the procedure of insertion of CVCs. The impact of the interventions on the results lead to the obvious question; what was practice like beforehand if they had such an effect? The interventions cited, other than the use of antibiotic-impregnated CVCs, would be regarded as routine practice in the majority of ICUs in this country. The implication that this wasn't the case prior to their formal introduction in the unit in question would account for their high rates of infection at the outset. The changes in infection rates immediately following antibiotic impregnated CVCs introduction on the graph in the article might be an accurate reflection of their clinical impact on the shopfloor i.e minimal in comparison to the other measures. The design of physical barriers between patients beds is highlighted, but the crucial feature in this intervention is surely the 5-fold increase in both handwashing stations and alcohol gel dispensers on the unit? It is interesting to note that the rates of infection begin to show a slow rise approximately 18 months to 2 years after the introduction of impregnated CVCs & handwashing campaign, and then again the same period after introduction of chlorhexidine. This could reflect the diminished impact of an intervention as both its novelty, ad strict adherence to it, wears off. There is a relatively high rate of infection even after the interventions are all in place, suggesting that there is still room for improvement, a feature no doubt not limited purely to this unit. Competing interests: None declared